Frank
Drum, 13, and his younger brother Jake are catapulted into adulthood the summer
of 1961 in their small Minnesota town as they become involved in investigation
of a series of violent deaths. Their
father, a Methodist minister, and their mother, a singer and musician, can’t
protect them from knowing more than children perhaps should know about suicide,
mental illness, and unprovoked violence.
The story is Frank’s retrospective, 40 years later, on that summer and
its lasting impact on their family, including what he and his brother learned
about the complicated ways people are driven to violence and the equally
complicated range of ways people respond to violence and loss—grief, anger, depression,
and sometimes slow and discerning forgiveness.

This is the third book in a series on the history of medicine and medical education by Kenneth M. Ludmerer, a practicing physician and historian of medicine at Washington University of St. Louis. The first, Learning to Heal: The Development of American Medical Education, published in 1985, dealt with the history of medical schools and medical education in the US from their origins in the 19th century to the late 20th century. In 1999 he published Time to Heal: Medical Education from 1900 to the Era of Managed Care. This book, Let Me Heal: The Opportunity to Preserve Excellence in American Medicine, published in 2015, is a sweeping history of graduate medical education in the United States from its inception to the current day.

In 13 chapters and 431 pages (334 pages of text, 97 of reference and index), Ludmerer traces the residency from early apprenticeship days to its metamorphosis (at Johns Hopkins, of which he is a justly proud medical school alumnus) into the embryonic form of what we now call an internship and residency. Giants like “The Four Doctors” (to use the title of John Singer Sargent’s famous portrait of William S. Halsted, William Osler, Howard A. Kelly and William H. Welch - but known simply as “The Big Four” at Hopkins) were the godfathers of the American postgraduate medical model which emphasized clinical science, teaching, patient care and research. The rise of acute care teaching hospitals as the venue of postgraduate medical education, and not the medical school or university, is an interesting story and one which Ludmerer tells in great detail over a number of chapters. It is one replete with predictable turf wars, professional turmoil and politics, and societal change in all aspects of the 20th century. This last phenomenon receives its due attention in every chapter but is dissected in meticulous detail in the final chapters dealing with the Libby Zion case, duty hours and the increasing role of the Accreditation Council for Graduate Medical Education (ACGME) in postgraduate medical education.

Beginning in the 1930’s, American medicine grew increasingly specialized and, in the ensuing decades, subspecialized, much to the consternation of pre-WW II general practitioners who, suddenly and for the first time, found themselves in the minority, in numbers and in influence, of their own profession. Concomitant with the phenomenon of specialization was the imprimatur by academic medicine of the structured, sanctioned residency as the sole route to specialty practice with, of course, the birth of associated accrediting agencies. Along with the move, physically, academically and politically, of postgraduate medical education to acute care teaching hospitals, the control of this education moved from medical schools to the profession at large.

Ludmerer deftly describes the “era of abundance”, the salad days of postgraduate medical education in the 1950’s and 1960’s when giants still made rounds on the floors of postgraduate medical venues; funds were plentiful; outside criticism was an as yet unborn bête noir; and social, economic and governmental curbs were only a tiny distant cloud in an otherwise blue sky. Ludmerer is correct in attributing much of medicine’s professional and social hegemony as well as its transient immunity to criticism in this era to the following evident successes of medicine: antibiotics; initial inroads into antineoplastic therapies; startling technological innovations in imaging; a burgeoning spate of life-saving vaccines; and spectacular advances in surgery, especially pediatric, cardiothoracic and transplant. Fatal diseases of the 1930’s and 1940’s were now often cured in days and of historical interest only.

Like all salad days, those of medicine eventually succumbed to new historical forces: foreign medical graduates in the workplace; the ever-growing financial burden of the residency; and economic pressures like Medicare and its associated regulation. There were other factors, too: professional and societal expectations of standardization and quality care; the explosion in subspecialties; the horrid wastefulness of unnecessary diagnostic tests and therapies borne of an earlier undisciplined abundance; the supercession of the intimate primary physician-patient relationship by the fragmented care of specialists and the rising supremacy of technology over personalized histories and careful physical examinations (why percuss the abdomen when you can get a CAT scan?). Dissatisfaction amongst residents is a dominant theme Ludmerer rightly raises early and often: the conflict and tension between education and service, between reasonable work and “scut”, between being a student and a worker (at times, quite a lowly one).

”High throughput” - the much more rapid turnaround time between admission to an hospital and discharge - has radically changed forever the entire nature of postgraduate medical education, and not for the better in the eyes of the author and of this reviewer, who were fellow residents a lifetime ago at Washington University in St. Louis. This decreased length of stay, a result of the remarkable improvements in diagnosis and therapy mentioned above, meant that the working life of providers (attending physicians, residents, physician assistants and nurses) was in high gear from admission to discharge, thereby increasing tension, likelihood for error and, exponentially, the workload for the resident while simultaneously and irrevocably damaging the possibility of a meaningful, careful provider-patient relationship (like a friendship, of which it is a subspecies, such relationships can not be rushed) and decreasing opportunities for learning. Medicare; changing patient populations; societal and professional disgruntlement; the Libby Zion mess and the ensuing cascade of regulations from all sides, but most especially the ACGME - all receive careful and systematic treatment in the final chapters of this monograph.

Ludmerer ends with a chapter listing what he sees as opportunities for achieving (or re-achieving) excellence. Indeed, he has made it the book’s subtitle. They are the following: a plea for the ACGME to revise its 2011 duty-hour regulations; an equally earnest hope that interns and residents will soon realize a more manageable patient load; a related wish for academic medicine to decrease the unfortunate occurrence of economic exploitation of house officers; a suggestion that this annotator shares, i.e., that the process of supervision, improved (but inadequately) with recent ACGME requirements, be further strengthened; and a hope that medical schools will restore teaching to the central place in the institutional value system it used to enjoy. Ludmerer issues a call for the more vigorous promotion of “an agenda of safety and quality in patient care” (page 312) and suggests that the education of residents be expanded to include venues outside in-patient sites. Elsewhere in the book, he also expresses the expectation that the inclusion into clinical teaching of private patients alongside “ward” patients, more feasible with recent improvements in the re-imbursement of medical care, be routine and maximized to the enjoyment and benefit of all concerned.

Many are familiar with these stories from the author's practice as a midwife among the urban poor in London's East End in the 1950s. Each piece stands alone as a story about a particular case. Many of them are rich with the drama of emergency interventions, birth in complicated families (most of them poor), home births in squalid conditions, and the efforts of midwives to improve public health services, sanitation, and pre- and post-natal care with limited resources in a city decimated by wartime bombings. As a gallery of the different types of women in the Anglican religious order that housed the midwives and administered their services, and the different types of women who lived, survived, and even thrived in the most depressing part of London, the book provides a fascinating angle on social and medical history and women's studies.

When nine-year-old Rob Cole, child of poor 11th-century
English farmers, loses his mother, he is consigned to the care of a
barber-surgeon who takes him around the countryside, teaching him to juggle,
sell potions of questionable value, and assist him in basic medical care that
ranges from good practical first-aid to useless ritual. When, eight years later, his mentor dies, Rob
takes the wagon, horse, and trappings and embarks on a life-changing journey
across Europe to learn real medicine from Avicenna in Persia. Through a Jewish physician practicing in
England, he has learned that Avicenna’s school is the only place to learn real
medicine and develop the gift he has come to recognize in himself. In addition to skill, he discovers in
encounters with patients that he has sharp and accurate intuitions about their
conditions, but little learning to enable him to heal them. The journey with a caravan of Jewish
merchants involves many trials, including arduous efforts to learn Persian and
pass himself off as a Jew, since Christians are treated with hostility in the
Muslim lands he is about to enter.
Refused at first at Avicenna’s school, he finally receives help from the
Shah and becomes a star student. His
medical education culminates in travel as far as India, and illegal ventures
into the body as he dissects the dead under cover of darkness. Ultimately he marries the daughter of a
Scottish merchant he had met but parted with in his outgoing journey, and,
fleeing the dangers of war, returns with her and their two sons to the British
Isles, where he sets up practice in Scotland.

This memoir focuses on the various ways in which his being
an African American affected Tweedy’s medical education and early practice as a
medical resident and later in psychiatry. Raised in the relative safety and
privilege of an intact family, he found himself underprepared for some of the
blatant forms of personal prejudice and institutional racism he encountered in
his first years of medical education at Duke Medical School. One shocking moment he recounts in some
detail occurred when a professor, seeing him seated in the lecture hall,
assumed he’d come to fix the lights.
Other distressing learning moments occur in his work at a clinic serving
the rural poor, mostly black patients, where he comes to a new, heightened
awareness of the socioeconomic forces that entrap them and how their lives and
health are circumscribed and often shortened by those forces. Well into his early years of practice he
notices, with more and more awareness of social contexts and political forces,
how the color line continues to make a difference in professional life, though
in subtler ways. The narrative recounts clearly
and judiciously the moments of recognition and decision that have shaped his
subsequent medical career.

Blow’s account of growing up in rural Louisiana, exposed to
negligence, sexual molestation, violence, and loss focuses on a child’s
strategies of survival first, and then on sexual confusion, social ambition,
and discovery of the gifts that led him to his life as a writer for the New York Times. A major theme in the memoir is his learning
to claim his bisexuality after years of secrecy and shame. That emergent fact about his identity, along
with moving to New York after a life in the rural South required an unusual
level of self-reflection and hard, costly choices that challenged norms at
every level. His account of learning to
assume a leadership role in a college fraternity and deciding to finally leave it behind
offers a particularly vivid example of what it takes to resist perpetuating
rites of humiliation and conformity designed to curb individuation.

Born in 1921 to Jewish immigrant parents, “Barney” Barnett
describes his life in medicine and education, from his earliest love of science
and learning through his medical and residency education in general internal
medicine, his success as an academic physician, and finally his judicious
decision to retire.

An important leitmotiv is the antisemitism of the University of Toronto that
kept him from a residency position (he went to Minneapolis) and a staff
position (he was offered a one-year fellowship on a low salary in 1951).
Even after he was accepted as a staff member at the Toronto General
Hospital (TGH), he was not promoted. Although he referred many patients to his
TGH colleagues, only six ever returned the favor in the thirteen years he was
there. Ironically, his Jewish background plucked him from this pedestrian
position directly to the seat of Physician in Chief of Toronto’s Mount Sinai
hospital (founded 1922) when finally it became a teaching hospital in
1964.

While maintaining a practice in internal medicine, Berris became a liver
specialist and researcher who introduced liver biopsy to Toronto. Known as a
consummate diagnostician, he endeavored to enhance the research profile of his
institution, integrating it with bedside instruction. He served on examining
committees for the Royal College of Physicians and Surgeons, candidly
describing the subjectivity of the process. He also served on many committees
of the College of Physicians of Ontario, including discipline, and describes the process used to investigate complaints with
case examples.

His story includes vivid descriptions of some of the most famous figures in
Canadian medical history, his teachers and colleagues – J.B. Grant, Arthur W.
Ham, William Boyd, Ray Farquharson, K.J.R.Wightman, Arthur Squires, and Arnold
Aberman. He was once involved with the care of the wife of David Ben-Gurion and
Queen Elizabeth II.

Little is told of his personal life, although he admits that he often neglected
his family for the press of work. His first wife, Marie, was a social worker;
they had three children, one now a physician. She died of ovarian cancer; to
care for her, he stepped down as chief in 1977. In 1984, he married
Thelma Rosen, an expert in education and widow of a pediatrician colleague.
Together they went on a year’s sabbatical that allowed him to work in
Singapore, Stanford University, and Sheila Sherlock’s lab at the Royal Free
Hospital in London.

Some of the most engaging chapters contain clinical vignettes: stories about
patients, the diagnostic workup, and their outcomes. Like Richard
Goldbloom (A
Lucky Life) and without diminishing his native abilities (which must have
been considerable), he modestly attributes most of his success to
luck.

Minna Bernays is the younger sister
of Martha, Sigmund Freud's wife. Her own fiancé has died and by 1895,
she is reduced to joining her sister’s family in Vienna because she has abandoned
her position as a companion to a demanding, prejudiced aristocrat. The six Freud
children love her, but she finds them exhausting and undisciplined. Obsessed
with order, housework, and social standing, and possibly suffering from psychosomatic ailments, Martha is happy to leave the care
of the children to Minna. She disapproves of her husband’s theories about
sexual frustration as a cause of mental distress and refuses to discuss his
ideas. Nevertheless, Martha is well aware that growing anti-semitism hampers
her husband’s career, and she is eager for him to succeed: he could consider a
conversion of convenience, like the composer Gustav Mahler.

Minna finds herself drawn to Sigmund for
his intellect and his novel ideas. She is also attracted to him physically, and
he to her. She resists the temptation, but he does not and actively pursues
her, inducing her to try cocaine too. He justifies it - the sex and the drugs - as
necessities for mental and physical well-being and he rejects the guilt that, he
claims, so-called civilization would impose.

She tries to leave by finding another job
as a ladies’ companion in Frankfurt, but he follows her there. They escape for an
idyllic holiday to a hotel in Switzerland, then he brings her back to the family
home. But his ardor cools and she is wounded, displaced by his enthusiasm for Wilhelm Fliess and Lou Andreas-Salomé.

Soon she discovers that she is pregnant,
and Freud sends her away to a “spa” for an abortion, but at the last moment,
she decides to keep her baby. Sadly she miscarries and returns to the Freud
family with whom she remains for more than four decades until her death in
1941.

Performance poet Bao Phi was born in Saigon; his parents emigrated to Minnesota, where he grew up and still lives. His poetry is rooted in Asian American immigrant experience, especially in Vietnamese American experiences, and speaks of racism, economic hardship, cultural difference, and the legacy of the Vietnam war. The collection is divided into four sections, each preceded by a quote from another (usually Asian American) writer. Four introductory poems set the tone for the poet's project of "refugeography" (from "You Bring Out the Vietnamese in Me", p. 9): recognition and celebration of the variety of Asian American lives, and anger at exploitation - both economic and cultural: "They box our geography / And sell it in bougie boutiques / Our culture quite profitable / But can somebody tell me / How our culture can be hip / And yet our people remain invisible?" ("For Us", p. 1)

In section 2 (The Nguyens) 14 poems highlight the lives of a variety of unrelated individuals and families across the US who have the same family name. "They are one story for every Viet body, one song for every voice that sings or otherwise" (p. 17). Many are angry and bitter. There is the Sacramento girl who grows up, makes good, and wants now to get even with the white boy who pushed her down and called her "gook" in ninth grade: "where is your wheat- haired crown now, / where is your Made- in- America tongue: / a slide of spit to take me back to where I came from / now that I am ready to show you / show you / where I come from" ("Vu Nguyen's Revenge", p. 20). There is the chef who had once worked in the kitchen of a restaurant where the waitstaff was white only: "let me tell you that the white people / can choke to death on their lychee martinis" ("Fusion", p. 24). Others are reflective - such as the soldier in Iraq who meditates, "let me not tear apart a people, a country, causing Iraqi food to / become the nouvelle cuisine in 25 years back home" ("Mercy", p. 29).

Some wrestle with generational misunderstanding: Dotty from Dallas whose mother "hid the food stamps by holding [her] hand out like a fan of shame at the checkout line" and later kicked her out of the family, accusing her of being a "Commie" (p. 45). There is tongue in cheek irony, such as in "The Nguyen Twins Find Adoration in the Poetry World" (p. 40), about two vastly different poets - Joan, who has an Anglo boyfriend, publishes in respected traditional literary journals, includes in her work Vietnamese sentences "she never fails to translate" and who won the "safe ethnic poet award"; and Jesus, whose poems are "system fascist overthrow racism working class" performed on Def Poetry Jam where he mispronounces all three of the only Vietnamese words he uses in his poetry.

Numerous poems in sections 3 and 4 address racism. "Reverse Racism" (p. 59) imagines the tables being turned on whites: schools that teach only Asian-American history and suspend any student who questions it; jobs that "stick white men in middle -management hell, then put them on a pedestal as an example of how whites can be successful", and "when white men form their own groups to protect themselves, I'll accuse them of being separatists and reverse racists". "Dear Senator McCain" (p. 65) begins with a quote from the year 2000 in which the senator (who had been imprisoned and tortured by the North Vietnamese during the Vietnam war) says, "I hate the gooks. I will hate them as long as I live." The poem issues a challenge: "I am that gook waiting in your nightmare jungle / that gook in front of you with 17 items in the 10 items or less lane at the supermarket / that gook born with a grenade in his head / that gook that got a better grade than you in shop class" and ends, "Senator / what's the difference / between an Asian /and a gook / to you".

Another poem ("8 [9]", p. 93) is based on the 2006 killing of a 19-year-old Hmong American by a white policeman in Minneapolis. There is despair ("For Colored Boys in Danger of Sudden Unexplained Nocturnal Death Syndrome and All the Rest for Whom Considering Suicide Is Not Enuf ", p. 82 ). There are also poems of self-awareness, for example, of the dichotomy of an earlier ghetto life and a later "fancy college" experience ("Called [An Open Letter to Myself]", p. 76); intra-ethnic suspicion and misunderstanding ("Everyday People", p. 99); energy and pride ("Yellowbrown Babies for the Revolution", p. 86).

This is a compendium of original critical essays on a wide range of topics written by a diverse group of scholars of what has traditionally been called "medical humanities." The editors argue for a change of name to "health humanities," pointing out that "medical" has a narrow frame of reference - evoking primarily the point of view of physicians and their interaction with patients, as well as the institution of biomedicine. Such a focus may exclude the myriad allied individuals and communities who work with patients and their families. The editors quote Daniel Goldberg, who notes that the health humanities should have the primary goal of "health and human flourishing rather than . . the delivery of medical care" (quoted on page 7).

The three editors are innovative contemporary scholar-educators in the field of medical/health humanities. They advocate Megan Boler's "pedagogy of discomfort" (quoted on page 8) and wish to provide students and educators "an opportunity to examine critically the origins and nature of their personal beliefs and values, beliefs and values embedded in the curriculum and the learning environment, as well as institutional policies - all of which intersect" . . and influence quality of care (8). In their own work and in this Reader the editors favor an approach to health humanities education and research that "challenge[s] the hegemony of a biomedicine that contributes to disparities and the discrimination of persons who don't quite fit the codified and naturalized norms of health."

The book is divided into 12 parts, each comprising three or four chapters: Disease and Illness, Disability, Death and Dying, Patient-Professional Relationships, The Body, Gender and Sexuality, Race and Class, Aging, Mental Illness, Spirituality and Religion, Science and Technology, and Health Professions Education. At the end of each section there is "an imaginative or reflective piece" on the topic. A wide range of disciplines is represented, including disability studies, history, bioethics, philosophy, literature, media studies, law, and medicine. Some of the authors are well-known and have been practicing their profession for many years (for example, Arthur Frank, Sander Gilman, Anne Hudson Jones, Martha Montello, John Lantos) while others have entered the field more recently and are gaining increasing attention (for example, Rebecca Garden, Daniel Goldberg, Allan Peterkin, Sayantani DasGupta).

The Reader is well documented: there are footnotes at the end of most chapters, a references section of 50 pages, notes on contributors, and a 72-page index.